Instructions how to answer: For each question choose the appropriate answer. If you are unsure about how to answer a question, please give the best answer you can. These questions are about your lungs. The information you give should describe how you feel. You can also indicate how capable you are of carrying out your usual activities.
During the past 4 weeks, how often have you had any of the following symptoms (problems) from you lungs?
2.1
Pain behind or between the shoulder blades?
2.2
Pain in the chest area?
2.3
Pain in the back area?
2.4
Feeling of pressure in the chest?
2.5
Feeling that there is 'still something there'?
2.6
'Burning sensation' in the lungs?
2.7
'Nagging feeling' in the lungs?
2.8
Difficulty in breathing or breathlessness?
3.1
At what time or day are your lung symptoms strongest?
4.1
Compared to 1 year ago, how would you rate the condition of your lungs in general now?
The following items are about activities that you might do in a typical day. Do your lung symptoms now limit you in these activities? If so, how much?
5.1
Daily activities at work
5.2
Daily activities at home (e.g. housework, ironing, doing odd jobs/repairs around the house, gardening, etc...)
5.3
Social activities (such as travelling, going to the cinema, parties, shopping)
5.4
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
5.5
Moderate activities, such as moving a table, hoovering, swimming or cycling
5.6
Lifting or carrying groceries
5.7
Climbing several flights of stairs
5.8
Climbing 1 flight of stairs
5.9
bending, kneeling or squatting
5.10
Walking more than half a mile
5.11
Walking a couple of hundred yards
5.12
Walking about one hundred yards
5.13
Washing or dressing yourself
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your lungs?
6.1
Had to cut down the amount of time you spent on work or other activities
6.2
Managed to do less than you would like
6.3
Were limited in the kind of work or other activities
6.4
Had difficulty performing work or other activities (e.g. it took extra effort)
7.1
During the past 4 weeks, to what extent have your lung symptoms interfered with your normal social activities with family, friends, neighbours or other groups of people?
8.1
How much pain around your shoulder blades/pain in your chest have you experienced during the past 4 weeks?
9.1
How much breathlessness have you experienced in the past 4 weeks?
These questions are about how you feel and how things have been with you during the past 4 weeks as a result of your lung symptoms. For each question, please give the one answer that comes closest to the way you have been feeling most of the time during the past 4 weeks.
10.1
Were you worried about having another pulmonary embolism?
10.2
Did you feel irritable?
10.3
Would you have been afraid if you had to stop taking anticoagulant (blood thinning) medication?
10.4
Did you become emotional more easily?
10.5
Did it bother you that you became emotional more quickly?
10.6
Were you depressed or in low spirits?
10.7
Did you feel that you were a burden to your family and friends?
10.8
Were you afraid tot exert yourself?
10.9
Did you feel limited in taking a trip?
10.10
Were you afraid of being alone?
How often per week
Q2
Compared to one year ago
Q4
Limitations
Yes - no
Q6
Q7
Q9